VNA of Orange County LLC - Hospice

“It is required that the hospice implements emergency preparedness (EP) policies and procedures, that address the minimum information provided to facilitate patient evacuation and transportation including if the patient is mobile or not; if the patient has life-dependent equipment, and if so, is it able to be transported (e.g. battery operated, size, condition, etc.); and any patient special needs including cognitive disorders, intellectual disabilities, or communication issues (e.g. deaf, non-English speaking, etc.). This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) of start of care records reviewed it was revealed that the organization did not ensure that the records included the minimum information required to facilitate patient evacuation and transportation. Clinical Record 2: The patient was admitted to hospice services on 06/07/2024 with a terminal diagnosis of malignant neoplasm of the accessory sinus and revoked services on 06/11/2024. A concurrent review of the clinical record and interview with the Director of Patient Care Services (DPCS) on 11/14/2024 revealed that the record did not include a documented emergency plan including minimum information to facilitate patient evacuation and if the patient had life-dependent equipment that would need to be considered in an emergency. The DPCS stated, “This patient was in an SNF so we definitely should have documented a coordinated plan for supporting the safe evacuation of this patient. I get it.” Clinical Record 10: The patient was admitted to hospice services in Benefit Period 1 effective 10/03/2024-12/31/2024 with terminal and pertinent diagnoses that included Secondary malignant neoplasm of the right lung, COVID-19, and oxygen dependence. A concurrent review of the clinical record and interview with the DPCS on 11/14/2024 revealed that the record did not include minimum information to facilitate patient evacuation including how the patient would transport (i.e. wheelchair) and how much supplemental oxygen would be required for the oxygen-dependent patient. “The plan of care indicated that an emergency plan was established but you are correct that there is no place in the patient’s clinical record that there is an emergency plan documented.” Clinical Record 11: The patient was admitted to hospice services in Benefit Period 10 on 10/23/2024-12/21/2024 with terminal and pertinent diagnoses that included hypertensive heart disease with heart failure, history of falls, TIA, COPD, and oxygen dependence. A concurrent review of the clinical record and interview with the DPCS on 11/14/2024 revealed that the record did not include a documented emergency plan that included minimum information to facilitate patient evacuation including how the patient would transport (i.e. wheelchair) and how much supplemental oxygen would be required for the oxygen-dependent patient. Clinical Record 13: The patient was admitted to hospice services on 09/05/2024-12/03/2024 in Benefit Period 1 with terminal and pertinent diagnoses that included end-stage cardiac disease, AFIB, Parkinsonism, and Myelodysplastic Syndrome. A concurrent review of the clinical record and interview with the DPCS on 11/14/2024 revealed that the record did not include a documented emergency plan that included minimum information to facilitate patient evacuation including how the patient would transport (i.e. wheelchair) and any life-dependent equipment such as supplemental oxygen.”

“It is required that a registered nurse makes an annual on-site visit to the location where a patient is receiving care in order to observe and assess each hospice aide while he or she is performing care per the hospice’s policies and procedures. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) of hospice aide personnel files reviewed it was revealed that the organization did not ensure that an annual on-site visit was performed and documented. Personnel Record 8: The hospice aide was hired on 12/16/2004. The Administrator confirmed that the personnel file included no record of a documented annual on-site visit to observe the aide while she was performing care in 2023 or thus far in 2024. The Director of Patient Care Services (DPCS) stated, “I know the RNs see the aides all of the time, sometimes they even do joint visits together. I guess it was just never documented.” The Administrator stated, “We have it scheduled for the RN and the Aide to do a visit together next week.””

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by document review, interview and personnel record review. In 5 of 9 (56%) of personnel records reviewed for personnel providing care, the organization did not ensure that the skills and competencies were completed annually in accordance with the organization’s policies and procedures. The Competency Program Policy, recently revised in December 2018, stated in part, “...After the completion of orientation, competency will be monitored annually thereafter as part of the annual performance evaluation process. ...Clinical competency of qualified evaluators (preceptors, supervisors, peers, clinical specialists) will also be defined and regularly evaluated. ...” Personnel Record 4: The MSW/Bereavement Coordinator was hired on 11/03/2020. The Administrator confirmed on 11/14/2024 that the assessment of skills and competencies of the Social Worker for the MSW role and the Bereavement Coordinator role had not been performed annually as required by organizational policy in 2023, or to date in 2024. She presented documents titled “annual competency assessment skills checklist social worker” and “annual competency assessment skills checklist bereavement coordinator” with the self-assessments completed by the social worker/bereavement coordinator dated 11/12/2024. The Administrator stated, “We’ll be getting this completed going forward but we don’t have any completed in the past couple of years.” Personnel Record 5: The Chaplain was hired on 01/05/2022. The Administrator confirmed on 11/14/2024 that assessment of skills and competencies of the Chaplain had not been performed annually as required by organizational policy in 2023, or to date in 2024. She presented a document titled “annual competency assessment skills checklist Chaplain” with the self-assessment completed by the Chaplain dated 11/13/2024. The Administrator stated, “We’ll be getting this completed going forward but we don’t have any completed in the past couple of years.” Personnel Record 6: The Volunteer Coordinator was hired on 08/02/2021. The Administrator confirmed on 11/14/2024 that assessment of skills and competencies of the Volunteer Coordinator had not been performed annually as required by organizational policy in 2023, or to date in 2024. She presented a document titled “annual competency assessment skills checklist Volunteer Coordinator” with the self-assessment completed by the RN dated 11/14/2024. The Administrator stated, “We’ll be getting this completed going forward but we don’t have any completed in the past couple of years.” Personnel Record 8: The Hospice Aide was hired on 12/16/2004. The Administrator confirmed on 11/14/2024 that the assessment of skills and competencies of the Aide had not been performed annually as required by organizational policy in 2023, or to date in 2024. “We will absolutely do that right away but don’t have anything documented to provide you today.” Personnel Record 9: The Registered Nurse (RN) was hired on 12/09/2013. The Administrator confirmed on 11/14/2024 that assessment of skills and competencies of the registered nurse had not been performed annually as required by organizational policy in 2023, or to date in 2024. She presented a document titled “annual competency assessment skills checklist Registered Nurse” with the self-assessment completed by the RN dated 11/14/2024. The Administrator stated, “We’ll be getting this completed going forward but we don’t have any completed in the past couple of years.””

“It is required that the Interdisciplinary Group documents in the patient record that the policies and procedures for managing and disposing of controlled medications is provided and discussed. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 2 (50%) of death records reviewed, the organization did not ensure that the disposal of controlled medications was discussed and documented as required by organizational policy and procedure. Medication Management and Disposal of Controlled Substances patient/caregiver teaching sheet with a revision date of 09/2020 stated in part, “The hospice nurse, social worker, or chaplain attending the death of the hospice patient shall inform the family/caregivers of their responsibility to dispose of all the patient’s prescribed medications and shall document this instruction in a clinical note. ...” Clinical Record 3: The patient was admitted to hospice services on 10/11/2023, entered into Benefit Period 4 effective 06/07/2024-08/05/2024, and died on 06/12/2024 in a private residence. During concurrent clinical record review and interview with the DPCS on 11/14/2024, it was revealed that the RN who attended the patient’s death did not document that she informed the patient’s family of their responsibility to dispose of all medications according to organizational policy and procedure. The DPCS stated, “Our LVNs typically attend deaths and always remember to document family instruction of medication and controlled substance disposal but our RNs are not used to doing it as much. I’m sure she did it but forgot to document that she did it.””

“It is required that the hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review, interview and observation. In 2 of 2 (100%) of clinical records reviewed for patients residing in a Skilled Nursing Facility (SNF), the organization did not ensure that the hospice plan of care specified which provider was responsible for performing the functions agreed upon and included in the plan of care. Clinical Record 2: The patient was admitted to hospice services on 06/07/2024 with a terminal diagnosis of malignant neoplasm of the accessory sinus and revoked services on 06/11/2024. A concurrent review of the clinical record and interview with the Director of Patient Care Services (DPCS) on 11/14/2024 revealed that the plan of care did not specify what functions the SNF was responsible for and what the hospice was responsible for. The DPCS stated, “We have a delineation of responsibilities document that admitting RN completes for all SNF patients and places in the facility binder. We don’t bring it back and put it in our records though. I understand now that the plan of care would need to be the same in both places (the SNF and the hospice record).” Clinical Record 13/Home Visit 2: The patient was admitted to hospice services on 09/05/2024-12/03/2024 in Benefit Period 1 with terminal and pertinent diagnoses that included end-stage cardiac disease, AFIB, Parkinsonism, and Myelodysplastic Syndrome. A concurrent review of the clinical record and interview with the DPCS on 11/14/2024 revealed that the plan of care did not specify what functions the SNF was responsible for and what the hospice was responsible for. During the home visit with the hospice aide (Personnel Record 8) the patient’s folder was reviewed which contained a document that included a delineation of responsibilities section that did not specify what functions the SNF was responsible for and what the hospice was responsible for. The document indicated the frequency of visits provided by the Hospice SN, MSW, Chaplain, and Aide.”